Harvard PEPFAR BotswanaNigeriaTanzaniaTotal Persons enrolled in HIV Care 18,687* 91,87571, ,487* Persons initiated on ART 13,275* 118,295 61,69644,404129,375* Persons currently on ART 8,686* 103,159 47,668 28,84385,197* Number of ART Facilities CMT sites and adults only; Botswana National ART program “Masa” - calculated

Botswana’s Masa Program Africa’s first national program to provide free ART therapy to HIV/AIDS patients (2002). 32 ART hospitals and 136 satellite clinics 103,159 patients on ART in the public sector –61.6% female; 7.6% children 12,565 patients out-sourced from the public to the private sector

Master Trainer/ARV Site Support Program ClinicalLaboratory Monitoring & Evaluation Unit (within Masa): Linked to: All ARV sites Other MOH programs Masa BHP-PEPFAR ARV Site Support Program

Clinical Master Trainer ARV Site Support Program Clinical Master Trainer Corps (CMT) Program Director Program Coordinator Train site-level staff as local Master Trainers, Support ARV sites Train Nurse Prescribers, Dispensers & Support Staff  4 Physician Master Trainers  2 Pediatrician Master Trainers  2 Pharmacist Master Trainers 4 Nurse-Midwife Master Trainers

Clinical Master Trainers Training curricula and materials development Training (4,000 in formal training) –Nurse Prescriber & Dispenser –Nurse Dispenser –KITSO Introduction to AIDS Clinical Care –KITSO AIDS Clinical Care Fundamentals –Quality Assurance and Improvement (QAI) Failure management registries –all 32 sites sensitized and 20 of these now have an established reporting system.

Laboratory Master Trainer Lab Support Program: Laboratory Master Trainer Corps (LMT) 2 Lab Master Trainers (Assigned by Government) 3 Non-government Lab Master Trainers Train site-level lab personnel as site Master Trainers Lab Master Trainer Coordinator

Laboratory Master Trainers Decentralization of Labs –CD4s - 21 labs –VL – 8 labs New National Lab Training Manual completed Formal Lab Training (125 Lab Staff) –Sample Collection and Processing –CD4 –Viral Load Responsible for 100% of CD4 & VL Testing in country

M&E Unit HIV/AIDS INFORMATION MANAGEMENT M&E Unit M&E Specialist 3 Data Managers M&E Officer ACHAP Funded M&E Officer ACHAP Funded Data Clerks Link to ARV clinic sites Link to Master Trainer/ARV Site Support Program Data Quality Officer IT specialist ACHAP Funded IT specialist ACHAP Funded

Tanzania Harvard- PEPFAR Program Collaborating institutions (MDH) –Muhimbili University of Health & Allied Sciences (MUHAS) –Dar es Salaam City Council –Harvard School of Public Health

MDH supported sites in Dar es Salaam PUBLIC PRIVATE

Cumulative Ever Enrolled Into HIV care 71,925 Active on ART 28,843 (65%) Cumulative Ever Initiated on ART 44,404 (61.7%) MDH – ART Services Patient Enrollment 27 Public 14 Private 1 Faith-based 68 PMTCT sites 12 TB/HIV sites

Patient Tracking and Retention Total Enrolled in Care – 71,925 –Ever Initiated on ART – 44,404 (61.7%) Currently active on ART – 28,843 (65%) Not active on ART – 15,561(35%) –Stopped treatment – 662 –Transferred out – 2831 –Died – 3782 –Status unknown– 8286 (Being tracked)

MDH- Tanzania - PMTCT Uptake HIV tested10,97335,89368,28939,261 Tested HIV Positive 1,2123,1895,7813,345 Received ARV Prophylaxis 2201,0301,9091,434

MDH Program, Tanzania Change in CD4+ cell count Months from ART Initiation n=13,757

Roll-out to Private Sector MoU with 14 private hospitals 11.4% of all enrolled from Private facilities Prioritized areas of collaboration: –Training –Lab support –Data management –Regular supportive supervision and TA –Patient tracking

APIN/Harvard PEPFAR Sites: as of 2007 APIN Program Offices Sites Under APIN Ltd Sites Under Harvard PEPFAR 68 Nigerian Army Reference Hospital Nigerian Institute for Medical Research National Military Hospital, ‘Creek’ Lagos University Teaching Hospital University of Lagos, College of Medicine Mushin General Hospital PHC-Iru Victoria Island Onikan Women’s Hospital 68 Nigerian Army Reference Hospital Nigerian Institute for Medical Research National Military Hospital, ‘Creek’ Lagos University Teaching Hospital University of Lagos, College of Medicine Mushin General Hospital PHC-Iru Victoria Island Onikan Women’s Hospital Sacred Heart Catholic Hospital Lantoro Federal Medical Centre Makurdi Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri University of Nigeria Teaching Hospital Ahmadu Bello University Teaching Hospital Widowcare Abakiliki Ebonyi Federal Medical Centre Nguru University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital APIN Plus/Harvard PEPFAR

APIN/PEPFAR Sites: 2009 APIN Program Office Sacred Heart Catholic Hospital Lantoro University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital University of Ibadan College of Medicine 3 Satellites under UCH Adeoyo Maternity Hospital 43 Oyo DOTS Centres Nigerian Institute for Medical Research Lagos University Teaching Hospital University of Lagos Coll. of Medicine Mushin General Hospital PHC-Iru Victoria Island Onikan Women’s Hospital Nigerian Institute for Medical Research Lagos University Teaching Hospital University of Lagos Coll. of Medicine Mushin General Hospital PHC-Iru Victoria Island Onikan Women’s Hospital 68 Nigerian Army Reference Hospital National Military Hospital, ‘Creek’ 68 Nigerian Army Reference Hospital National Military Hospital, ‘Creek’ Federal Medical Centre Makurdi Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs Jos University Teaching Hospital Our Lady of Apostles Hospital Jos 8 Satellite Hospitals, 44 PHCs University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri University of Maiduguri Teaching Hospital State Specialist Hospital Maiduguri Nursing Home Maiduguri University of Nigeria Teaching Hospital Ahmadu Bello University Teaching Hospital Widowcare Abakiliki Ebonyi Federal Medical Centre Nguru Sites Under Harvard PEPFAR Sites Under APIN Ltd APIN Plus/Harvard PEPFAR

Time to Virologic Failure in Nigeria (n=8552) Patients at > 12months ART; Virologic failure = >1000 copies/ml JUTH =4009; 68MH=875; NIMR= 1723; UMTH=1945 APIN Plus/Harvard PEPFAR ____

Patients on treatment for ≥12 months: 11,924 Men: 4,270 (36%) Women: 7,654 (64%) Women more likely to have VL≤400 c/mL at 12 months (64% vs. 60%; p = 0001) Meloni, S. et al Influence of gender on ART outcome APIN Plus/Harvard PEPFAR

Patients with ≥95% Adherence By Gender and Time on ART Meloni, S. et al APIN Plus/Harvard PEPFAR

Viral suppression versus immunologic criteria for antiretroviral treatment failure Evaluated by APIN Plus in Nigeria 8,569 individuals met the following criteria and were included in this analysis : –ART-naïve at baseline –Available CD4 and VL measurements at baseline and after 6 months on ART. –Excluded if both labs were not available at failure. Cost of VL monitoring (2-3x per year) is ~$50 per patient in year 1 and ~$30 thereafter APIN Plus/Harvard PEPFAR

Virologic failure without Immunologic failure Immunologic criteria had low sensitivity (38.6%) for true virologic failure APIN Plus/Harvard PEPFAR Low PPV (45.5%) not only would patients be switched unnecessarily, but a substantial number of virologic failures would also have been missed

Quality Improvement Assessment Methods Sampling –Review Period: 1 Year –Sample Size: Adult ART: Pediatric ART: 50 PMTCT: 50 Mothers, 50 Babies On-site chart reviews Database centered analysis Direct observation Interviews with health care providers S. Calvés, 2007 APIN Plus/Harvard PEPFAR

Treatment Failure Indicators Lab Data for evaluation of Failure Failure Criteria – per Clinical protocols Subsample New: enrolled ≤1 yr prior to assessment Maintenance: enrolled > 1 year prior to assessment Quality Improvement Assessment APIN Plus/Harvard PEPFAR

Unique innovations for training, clinical protocols and M & E tools – shared between countries with local adaptations. Each country has significant operational research to evaluate implementation. Common challenges that each country program faces: Increased demand with decreasing resources Short timeline for transition